School of Psychology
Doctorate in Clinical and Community Psychology
Major Research Project/Paper
Discussing causality with families in a family management and
therapy integrated service, a qualitative study with focus
groups.
Trainee: Andrew Newman, Trainee Clinical and
Community Psychologist, Exeter University
Research supervisor: Professor Janet Reibstein, Professor of
Clinical Psychology, Exeter University
Field collaborator: Frank Burbach, Consultant Clinical
Psychologist, Somerset Partnership Trust.
Target journal: British Journal of Clinical Psychology
Word count: Manuscript: 7,983
Appendices: 5,963
Submitted in partial fulfilment of the requirements for the Doctorate Degree in
Clinical and Community Psychology
Exeter University
2
Abstract Page 3
Introduction Page 4
Method Page 9
Design Page 9
Participants Page 10
Procedure Page 10
Analysis Strategy Page 11
Epistemology Page 11
Reflexivity Page 12
Results Page 13
Theme: Uncomfortable discussion Page 13
Theme: Constructing a shared understanding Page 14
Theme: Therapeutic style Page 16
Theme: Limiting exploration Page 17
Theme: Blame Page 20
Subtheme: The role of blame Page 20
Subtheme: Avoiding blame Page 21
Subtheme: Reducing blame Page 21
Discussion Page 22
Focus group dynamics Page 30
Limitations Page 31
References Page 33
Extended appendices Page 40
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Abstract
Objective. Family Therapy (FT) and Family Management (FM) approaches to
psychosis have been divided by their understanding of causality. FM holds a
biological understanding which has been identified as having negative
consequences for the person with psychosis. FT, by exploring family interactions has
been criticised for blaming families for causing their relations psychosis. These two
approaches have now been integrated, but how causality is discussed in an
integrated approach has only now been explored.
Design and methods. This qualitative research asked clinicians working in the most
established integrated service how they discuss causality. Four focus groups were
conducted and a framework approach using thematic analysis was used.
Results. Five themes were explored; uncomfortable discussion; constructing a
shared understanding; therapeutic style; limiting exploration; and blame.
Conclusion. Discussing causality with families was identified as uncomfortable.
However, through the development of a therapeutic-relationship three identified tools
can be used to construct a shared understanding of causality. The therapeutic style
of explorative conversation--based in FT, integrated with the stress-vulnerability
model--based in FM, was identified as an important aspect of an integrated model
that resolved criticisms levied at each individual approach. Factors that limited
exploration were identified as major challenges to causality discussions, but
techniques to remedy these problems were also identified. The risk of families
feeling blamed/blaming themselves and attempts to avoid/reduce blame made up a
dominant theme of the research. The research concludes by challenging the need to
avoid/reduce blame, arguing that blame should be openly explored within family
interventions.
4
Introduction
Working with families affected by psychosis is a field which has struggled to find
ways of dealing with the issue of causality1 and blame2, and therapeutic approaches
can be considered to fall within two broad camps – family therapy (FT3) and family
management (FM4) (Burbach, 1996). An overarching theme of FT is that clinicians
base their work on communication/interactional models of psychosis (Burbach,
1996). Many services that work from a FM framework begin with the premise that
“within some FT approaches an individual‟s symptoms of illness are seen as
manifestations of dysfunction within the family system” (Smith, Greggory & Higgs,
2007. P.31). Thus the conclusion presented by many FM services is that FT blames
families for causing psychosis (Hatfield, 1986). Clinicians working within FM can be
defined by their acceptance of a disease/biological formulation of psychosis
(Burbach, 1996). Emphasising a biological cause leads to its own problems, the
individual with psychosis is perceived as dangerous and unpredictable (Read,
Haslam, Sayce & Davies, 2006) and there is a more pessimistic outlook towards
recovery (Angermeyer & Matshinger, 1996).
There is however a third model emerging in which FM and FT are integrated
(Meddings, Gordon & Owen, 2010; Lobban, Barrowclough & Jones, 2005; Burbach
& Stanbridge, 1998, 2006). Burbach, Carter, Carter and Carter. (2007) argue that
integrating FM and FT hold an advantage over a pure model. However as the two
1 The focus of this paper is on what originally caused the psychosis and not on what causes relapse.
2 Many other areas of mental health have also struggled with this, however given the limited space available
psychosis was focused upon.
3 Although FT is referred to as if it were one approach it is not easy to say what FT is, as there are many differing
schools of thought (Rivett & Street, 2003).
4 FM is also referred to in the literature as family interventions and family work (Smith, Gregory, & Higgs 2007).
5
models have been divided by their understanding of causality it is unclear how
causality is conceptualised within an integrated model. Thus this is important to
research.
Families’ feelings about causality
Corrigan and Miller (2004) found family members related to a person with psychosis
reported feeling blamed for the onset of their family member’s disorder, felt
responsible for relapses, and felt they were themselves incompetent family
members. Gonzalez-Torres, et al. (2006) found parents blamed themselves for
causing psychosis and sometimes felt blamed by clinicians. Jones (2002) and
Askey, et al. (2009) found siblings felt their parents were to blame for their
brother/sisters’ mental health problem. However, contrary to Corrigan and Miller and
Gonzalez-Torres et al.’s findings, no parents blamed themselves. Despite this
difference families seem to apportion blame in some way for causing psychosis
within the unit itself. Stratton (2003) argues that families come to therapy seeking an
expert opinion on whom or what is to blame. Stancombe and White (2005) argue
that families are attuned to hear blame within the therapist’s talk.
Family therapy
The hypothesis that families are causative in generating or maintaining symptoms
provided much of the impetus for starting the field of FT (Wynne, et al. 1992). FT has
gone through transformations in thinking, and many writers have characterised this
as arriving in three distinct phases (Dallos & Draper, 2005). In the first phase the
idea that some families were pathogenic was clearly stated (Haley, 1959). The
theory of cybernetics was applied to families, with therapists as separate observers
6
of the system, interested in its interactions and communications (Dallos & Draper,
2005).
The second phase, second-order cybernetics, heralded the idea that therapists were
part of the system. With this came the idea that there was no objective truth, only a
subjective perception of an observer (Rivett & Street, 2003). There was a movement
away from looking for the truth about the cause of psychosis towards generating
hypotheses about individual family interactions. By the third phase FT had embraced
post-modernism and began to look at the influence of society on the family and
therapist (Dallos & Draper, 2005).
Arguably the most contemporary FT approach for psychosis is Open Dialogue (OD)
(Seikkula, et al. 2001). Seikkula, et al. (2006) found interventions that claim there is a
truth about the cause of psychosis, which they label a ‘stuck monologue’ are linked
to poorer recovery and higher rates of medication prescribing compared to OD. OD
takes a social constructionist approach to causality, in OD all the people involved in
the life of the person experiencing psychosis gather together with the aim of moving
away from a stuck monologue towards a more deliberate open to all dialogue about
the different perspectives on the problem (Seikkula, et al. 2001).
OD views the problem not as psychosis but rather the language that is used to
describe it (Seikkula, et al. 2003). In OD people are required to ‘tolerate uncertainty’
as different perspectives are heard and discussed (Seikkula, et al. 2006, P. 215).
However, Jones (2002) and Smith, et al. (2007) argue that it’s uncertainty regarding
causality that angers families and can lead them to feeling blamed.
A number of techniques have been developed to reduce/dissolve families’ sense of
blame. These include offering reasurance that parents’ behaviour is understandable
7
as a way of supporting their offspring (Burbach et al. 2010); constructing circularities
rather than linear causalites (Jones & Asen, 2002); and using a social constructionist
approach, in which there is no one, single, identifiable truth about causality, only
points of view (White & Epston, 1989; Seikkula, et al. 2001). Doan (1998, P.383)
argues that a social constructionist view of causality often ignores or downplays the
‘genetically likely stories.’ He argues for an integration of social constructionist and
biological understanding to provide a more balanced account.
In summary FT takes a social constructionist approach to causality discussions, from
a position that there is no one, single, identifiable truth about it. It considers the role
of family members within circularities but doesn’t make linear causal connections. It
has been criticised for accusing families of causing psychosis.
Family management
Whereas the origins of FT were connected to what caused psychosis, FM interested
itself with what led to relapse (Johnstone, 2001). Expressed Emotions (EE), a term
used to describe hostility, criticism, and emotional intrusiveness, was found to be
associated with relapse. However EE is explicitly said not to have a role in the initial
cause of psychosis (Smith et al. 2007).
A number of initial sessions are allocated to explore the original cause and relapse
triggers of psychosis (Onwumere, et al. 2009). To do this psychoeducation is used
which involves the application of Zubin and Spring’s (1977) stress-vulnerability
model (SVM). This model describes a vulnerability to psychosis being present at
birth or soon after. However just because one is vulnerable to psychosis doesn’t
mean one will develop it, as there needs to also be an exposure to stress. This
stress can be acute, in terms of major life events or ambient, which comes from
8
accumulated day-to-day stressors of life. The use of the SVM is coupled with
information which explicitly says there is no evidence to suggest families have a
causal role in psychosis but that they can help reduce the risk of relapse.
Although this was an attempt to create a bio-psycho-social model, Read et al. (2006)
argues that the biological factor tended to be over-emphasised. Indeed the
Knowledge About Psychosis Interview (KAPI) as recommended for use in FM (Smith
et al. 2007) offers a response that psychosis is a biological illness to be correct.
Emphasizing biology in causality runs the risk of parents drawing a genetics
conclusion that something bad was passed on from them to their offspring
(Goldacre, 2010). When psychosis is viewed as having a biological cause the
individual with psychosis is perceived as dangerous and unpredictable (Read et al.
2006) and there is a more pessimistic outlook towards recovery (Angermeyer &
Matshinger, 1996).
In summary FM’s biological emphasis has been shown to lead to challenges for
causality discussions and there is evidence that FT has led to some families feeling
blamed for causing psychosis. There is however a third model emerging in which FM
and FT are integrated (Meddings, et al. 2010; Lobban et al. 2005; Burbach &
Stanbridge, 1998, 2006). Burbach, et al. (2007) argue that the integration of FM and
FT holds advantages over a pure model. They argue that integrating the FT circular
view of causality with FM enables a non-blaming means of exploring the family
dynamics that may be maintaining the problem. However how this integration works
in practice hasn’t been researched.
Furthermore, ethically it’s felt important to explore whether causality can be
discussed without having negative consequences for the family or person with
9
psychosis. Burbach and Stanbridge’s (1998, 2006) model is the most established
integrated approach. Therefore it’s reasonable to investigate how the clinicians
working within this approach discuss causality, turning experiential knowledge into
primary evidence.
Aim
To explore how clinicians’ discuss the causality of psychosis with families within the
Family Support Service (FSS)5.
Method6
Design
All cited research on blame stemming from ideas about causality has come from
qualitative research. A large proportion of the literature on discussing causality with
families comes from clinicians/researchers’ description. However there is little
description available on how clinicians in an integrated service discuss causality. A
qualitative approach was felt the most appropriate means of developing this
description.
It has been argued that research that uses pre-existing groups elicit more
experiential reflections than one-to-one interviews (Palmer et al. 2010). Thus a focus
group methodology was used. A framework approach was used to analyse the data.
This allows a targeted method for generating results within a tight timeframe by
allowing themes to develop from the research questions (a-priori analysis). However,
5 The FSS is the family intervention service that uses the Burbach and Stanbridge (1998, 2006) integrated mode.
For a detailed explanation of the FSS please see Burbach and Stanbridge (1998, 2006) papers. 6 Research consultation was sought from Dr. Janet Smithson (Law research fellow of Exeter University) who has
written about conducting and analysing focus group data.
10
this approach ensures a comprehensive analysis by allowing themes to also develop
from participants’ narratives (in-vivo analysis) (Rabiee, 2004).
Participants7
The recruitment of the FSS was purposive and from that a voluntary sample was
drawn. This service has four teams; each team consists of four to six clinicians, with
a total of twenty-two in the service. Four hour-long focus groups were held (one with
each team) with four to five participants in each group, totalling eighteen
participants8. The participants were homogenous in that they had all completed the
same one-year training program and worked within the FSS. However the
participants had different professional backgrounds and some had completed
additional psychotherapy training9.
Procedure
The researcher attended a meeting of the FSS to introduce the idea of the research.
An invitation to participate10 was e-mailed to each clinician and consent to participate
was facilitated through replying to the e-mail. E-mail was used to reduce the risk of
peer pressure to participate. With the field collaborator’s assistance the researcher
arranged to attend each team’s meeting to conduct a focus group. Consent forms11
and information sheets12 were given to participants at the start of the focus group
providing a two-stage consent process. Ground rules were drawn up and the semi-
7 Ethical approval was granted from the NHS Ethic Committee, appendix Q.
8 Despite being a member of the FSS the research collaborator was not invited to take part in the focus groups
due to his level of involvement in the research. 9 Appendix O provides a table of participant‟s demographic details.
10 See appendix A for invitation to participate.
11 See appendix B for consent form.
12 See appendix C for information sheet.
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structured guide13 was used with the researcher (AN) acting as facilitator. The focus
groups were audio recorded to enable verbatim transcription by AN.
Analysis strategy
The data were thematically analysed by AN using a framework approach (Krueger &
Casey, 2009; Rabiee, 2004; Ritchie & Spencer, 1994). The framework approach has
the advantage of a clearly laid out procedure of data analysis which allows other
researchers to verify the findings and safeguard against selective perception
(Rabiee, 2004). This analysis followed five stages: familiarisation, indentifying a
thematic framework, indexing, charting, mapping and interpretation (Appendix E).
Although Appendix E lays out a linear development of analysis, a constant
comparative approach was used. The last three stages were repeated in a cyclical
way, moving from segments of text to whole transcripts and back to segments
(Barbour, 2007). In addition these steps were repeated following peer debriefing and
member checks.
Epistemology
Unlike other methods, no one epistemological position is required in framework
analysis. Researchers describe a continuum of epistemological positions with
essentialist/realist at one end and constructionist at the other (Braun & Clarke,
2006). My own stance sits somewhere between these poles and is akin to critical
realism (Bhaskar, 2002). This stance acknowledges that there is a reality out there,
but we can never know this reality for certain and the reality we observe is influenced
by social processes. Thus there is a reality of how clinician’s discuss causality with
13
See appendix D for semi-structured focus group interview guide.
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families but how this reality is experienced, observed and described is affected by
social processes.
Reflexivity
By reviewing the literature I developed views about discussing causality with
families, which affected the questions I asked and the themes I identified. My
previous training/practice in FM and FT has influenced my involvement and
interpretation because I have my own bias and preferences with regards to these
models. To attempt to guard against this I undertook a number of steps to improve
the credibility of the research, as follow:
1) Peer debriefing (Holloway & Wheeler, 2000): The analysis was discussed with my
supervisor, field collaborator and in a qualitative analysis group. Half of the
transcripts were double coded by my supervisor and field collaborator; 60% of the
codes matched and the themes were considered plausible.
2) Member checks (Webb & Kevern, 2002): Thematic maps and representative
quotes were fed back to the participants in a follow-up focus group. All the
participants were invited to this focus group and eleven participants attended. After
presenting the data, questions identified by Morgan (1999) were used to structure
the participants’ feedback14. They confirmed the plausibility of the identified analysis
but suggested some changes15 to descriptive names.
3) Audit trail (Barbour, 2007): The development of a chart16, map17, matrix18 and
interpretation sheet19 for each theme guard against an impressionistic analysis as
14
See appendix F for the questions used to structure the feedback focus group. 15
See appendix G for summary of the feedback focus group 16
See appendix H for an excerpt from a theme chart. 17
See appendix I for an example thematic map. 18
See appendix J for an example theme matrix.
13
the grouping of codes into themes is transparent (Barbour, 2007). A section of
indexed transcript20 and a section of the researcher’s diary21 are also presented to
further the transparency of analysis.
Results22
Seven themes were identified: 1. Desire for certainty. 2. Uncomfortable discussion.
3. Constructing a shared understanding. 4. Therapeutic skills. 5. Limiting exploration.
6. Blame. 7. Experiencing the self in a group. Themes one and seven aren’t
discussed in this paper but may be explored in a future paper, although interesting
material was generated it wasn’t as directly relevant to the research aim as the other
themes.
Uncomfortable discussion
Causality appeared to be an uncomfortable discussion to have with families because
of factors identified that limited exploration and the role of blame (discussed later).
Clinician’s felt that there was no prescribed ‘right time’ to talk about causality but all
the groups said they felt more comfortable talking about it when families specifically
ask.
Y423
Sometimes they ask for it, don‟t they, they want to talk about causes (L261-262)
Some groups identified that if not directly asked they touch upon causality
throughout the course of the intervention rather than allocating a space to talk about
it. Y2 called this „weaving‟ information in.
19
See appendix K for an example interpretation sheet. 20
See appendix L for an example of indexed transcript. 21
See appendix M for an excerpt from the research diary. 22
See appendix N for the theme summary table. 23
All names have been changed to codes to safe guard anonymity and family names have been changed to stars.
14
Y2 ... And umm, and weave that information in. Through questions and through exploration
rather than as traditionally presenting it...
Y3 I like your analogy about weaving things in, because I mean at the moment I‟ve got three
young people on my case...who have recently lost a parent...it‟s obviously been a significant
part of the development of their problems, you know. With two of them we can talk about it
now, with the third we can‟t really yet, we will, but not yet. But I think it‟s that significance,
it‟s almost that weaving as you say, bringing little bits in (L221-244).
By weaving information in clinicians could be more careful and thus less like to
cause offense. Most groups said that once the therapeutic-relationship was
established causality was easier to discuss and could be done so more directly.
C4 ...you know building up relationships with people because, I mean there are certain ways
which I feel you can be a bit more sometimes direct, once you‟ve got to know someone and
they‟ve got to know you and you know they are not just, they are not think(ing) you‟ve been
totally presumptuous and being sort of very directive... but that takes time, it takes time to get
this knowledge and umm and you know, get to know the family (L760-771).
As captured in this quote, all groups said that time to establish a therapeutic-
relationship was helpful when talking about causality.
Following a causality discussion a few groups said they ask the family how they
experienced the discussion. It was identified that the thought of talking about
causality was worse for the family than the actual discussion.
M4 Well often I‟ll sort of ask after a session, you know sort of say the words, how, how did
you find that? And you can...see the family...sort of feeling visibly relaxed almost, sort of that
was ok, that wasn‟t as bad as I thought
M3 Absolutely that‟s my experience; it‟s not as bad as they expected (L865-870).
Constructing a shared understanding
The purpose of causality discussions is to arrive at a shared understanding of what
caused the psychosis. A number of tools were described that aided this. The stress-
vulnerability model (SVM) was referred to as the most consistently used24.
24
Talking about causality is not necessarily different from talking about stress/vulnerability. Stress and
vulnerability are simply descriptive terms that can be used. When developing a formulation people tend to use the terms precipitating and predisposing rather than stress and vulnerability but they are very similar concepts.
15
M5 I find particularly the stress-vulnerability model is the one that crops up most often...I
find it‟s easy to use quiet often. (L251-254)
All groups identified positive aspects of the tool, indicating that it can be used
visually; it’s empowering, gentle/kind, flexible and enables multiple causal factors to
be considered in a way that wasn’t felt overly confusing.
Some groups spoke about using genograms. They described it as an active
approach to constructing a shared understanding that got people involved. Some
clinicians referred to it as good at uncovering trauma/genetic factors but others
expressed that you needed to be careful when using it.
Y2 ...I wouldn‟t do a genogram with the family too early on...it might also umm stir up a lot
of emotions. So umm you know pacing that and doing it carefully I think is very important.
(L361-370)
Interactional cycles25 were discussed in some groups but it was identified that they
weren’t used to look at causality.
T4 With the interactional cycles which, umm I would guess tend more on the side of what
maintains the difficulty rather than what‟s causal (L273-275).
Formulation was discussed by the groups who didn’t discuss genograms. These four
tools aren’t used in isolation and there is a sense that by combining them clinicians
can talk about cause, maintenance and moving on. However formulation was
considered to be the only tool that does all three.
T3...we do a formulation which, you know addresses or, these may have been predisposing factors
and umm and these are vulnerabilities and this is how it gets played out and I suppose that is causal
but then there‟s moving on to think about protective measures and people wanting help to just manage
better (L373-380).
25
Interactional cycles are similar to circularities but they make cognitions/attributions about family members
explicit, see Burbach, et al, (2007) for examples of interactional cycles.
16
Therapeutic Style
Therapeutic style was considered the most important factor for causality discussions.
This theme was talked about frequently and discussed at length in all groups. All
groups spoke of a style of ‘matching’ their intervention to the family’s needs. For
example; Y2 described how some families prefer to look at their family history and
others to focus on the future. So clinicians chose techniques and tools that match the
family’s preference in order to maintain their engagement.
Y2 Some people are... interested in umm hearing about past generations. Some people are
very in the present and future and not really, actually have an abhorrence...People will
sometimes say I‟m not going to talk to you, you know if you keep talking about the past... So
it‟s very important to discuss causes in a context that the family creates for you.
All groups said causality discussions generally took place within a style of
‘exploratory conversation,’ a term decided upon in the feedback focus group.
M3 I think that, you know when AN used the words „techniques‟ I think it is mainly about a
collaborative therapeutic conversation, most of the ways of introducing these different ideas
around causality are mostly conversational.
M2 Because that‟s rather different than a sort of teacher taught sort of situation.
M3 Yes
M2 I think a collaborative umm is, is, is a sort of, a rather non-expert sort of style of working,
isn‟t it? Where, where it‟s, you‟re not the sole source of knowledge and you‟re not, you‟re
not claiming that at all, you‟re actually interested in the many perspectives there might be in
facilitating something (L574-585).
Some groups spoke of needing to change to a more psychoeducational style at
times, particularly when discussing substance misuse. The majority of comments
within this theme were in general terms but M3 gave a practical example.
M3.... And I think, you know, that family that I mentioned earlier when we were talking
about drug use. I think I was quite explicit when I started talking to the siblings about drug
use and it could be seen as lecturing but I feel, you know if you, if there‟s clear drug use, you
know similar aged children to, maybe at university and ones got psychosis and has used
17
drugs, used cannabis for example. I think its information they need to have that they may be
at higher risk (L623-632).
However, not everyone agreed that there was a need to change from a style of
explorative conversation.
M2 ... I don‟t think risk outside of the session necessarily alters the way we are with the
family...
M5 Yeah (L663-665).
All groups commented that although the focus of the research is on causality, the
focus of the intervention is on changing the future. Families attend sessions with the
primary aim of improving their and the person experiencing psychosis’s life. It was
felt that exploratory future orientated conversations gave the family a sense that the
future could be different.
M2....I think there are ways in which having conversation can be empowering and have a
sense of agency in a situation rather than the feeling that there is something which is signed,
sealed and delivered, as it were (L240-243).
Limiting exploration
Although the intervention takes place within the style of exploratory conversation a
number of factors were identified that limit exploration. Familial sexual abuse was
identified by most groups as one such factor.
M3 ... I think it‟s a major challenge for family therapists now to sit in a room where there
might be somebody in that room a member of the family who might be an abuser, a sexual
abuser, someone who has committed a major abuse on maybe the client.(L277-279)
Although not appropriate to explore with the whole family a few groups identified that
familial sexual abuse could be explored by seeing different combinations of the
family. The abused may not feel comfortable raising the abuse in the presence of
18
some family members, but might be able to one-to-one or may feel supported by
certain family members to raise it.
Seeing different combinations of family members raises the issue of confidentiality.
Participants said that family members will often share information about a particular
causal factor in one combination of a family meeting but prohibit clinicians from
talking about it when other members of the family there. So although these factors
may have a causal role they cannot be explored or only explored in a limited way.
M5...I mean we sometimes have a situation in which drug use is clearly an issue possibly
with somebody‟s mental health difficulties but there‟s a, we‟re prohibited from discussing
drug use with families and that‟s quite often a confidentiality issue that patients, particularly
young patients talk about isn‟t it? (L167-172).
Some groups indicated that the issue of illicit drug use limited the exploration of
causal factors as although clinicians didn’t intend to express cultural/societal
judgments, clients sometimes experienced their comments in this way. As a result
clients often counter-argued, expressing their perception regarding the benefit of
drugs. Thus exploratory conversation became experienced as disagreement.
T4 ...you might get the response I smoke cannabis because umm my dad stresses me out
telling me not to smoke cannabis,...,and however much evidence you cite about lifestyle
choices it can be communicated in the wrong way or it can be received in the wrong way,
can‟t it? However you communicate it as
T3 Yeah, yeah
T4 As another form of oppression but actually “I‟m just managing the symptoms and I‟d
prefer to be out of it” (L518-526).
To guard against exploratory conversation becoming experienced as disagreement
participants referred to reflecting counterintuitively, e.g. reflecting on the benefits of
illicit drug use. Some groups also said that sensitive causal factors could be reflected
on with a colleague in the presence of the family rather than directly discussed with
19
them. A similar technique of sharing one’s own reflections rather than talking directly
to the family was identified; both forms of reflection were felt to facilitate exploration,
clarify and avoid disagreement.
Some groups spoke holding a care-coordination role for the family, due to service
restraints. They described how holding this more ‘active doing‟ role limited
exploratory conversation about causality as the family found it hard to see the
clinician outside of their active doing role.
C5 [Care-coordination is] More active
C3 Yeah, yeah, more active role. It‟s, it‟s kind of like, I‟ll sort that out and deal with that as if
care-coordinator rather than family role, let‟s see how we can move the family forward and
they couldn‟t. They couldn‟t see the difference in roles (L384-388).
Some groups identified client characteristics that meant the client didn’t have the
capacity to engage in exploratory conversation such as when the client was; in the
early stage of psychosis, very psychotic, too focused on their bodily experience and
clients who felt very isolated from their family, because in these situations concerns
other than causality were more pressing to them
Most groups identified specific family characteristics that limited/prevented the
exploration of causal factors. It was particularly challenging when families didn’t want
family interventions, or didn’t want to talk as the intervention requires the family to
engage in conversation. Similarly families that wanted to divest themselves of their
trauma and families with a biological focus were challenging as they weren’t open to
hearing other perspectives. However, over time and through the development of a
therapeutic-relationship these challenges could be overcome. There was however, a
sense that some families were too complex to ever engage in exploratory
conversation about causality, as some families find it impossible to
20
communicate/function together and are unable to be together with a focus on them.
This last point seemed an uncomfortable idea and M1 voiced how this sounded
blaming.
M1 ...you know how possibly families, families that perhaps find it so difficult to function
that it actually maybe actually is just too impossible, it‟s, it‟s impossible to be all in the same
room together. In in a, in a looking at them kind of way, I don‟t know. But then that‟s quite
blaming to sort of say that (laugh), it‟s because they‟re all messed up (laugh)... (L785-792).
Blame
The Role of Blame
Blame had a major role in shaping causality discussions. All groups discussed
people blaming themselves both explicitly and implicitly, as well as family members
blaming each other for causing psychosis. Clinicians said that although it wasn’t their
intention, family members sometimes felt they were blaming them.
T2 It‟s bringing to mind the conversation we had with *** the other day. That “if I’m to
blame for this then I might as well leave now.” Do you remember? They were just, weren‟t
going to discuss it. It wasn‟t that we were implying any blame or anything anyway but that
was how they were receiving it (L115-119).
Blame was identified as the major reason family members didn’t attend sessions or
dropped out of the intervention.
M1 ... we‟ve wondered about somebody who was absent to begin with
M3 Yes
M1...we were wondering whether...that particular person perhaps felt they might be blamed
for what, for what has happened (L878-885).
The strongest emotional response in all of the groups came from M1 who expressed
his guilt for when interventions went wrong and his difficulty in talking about it.
Although not explicitly linked to blame it was connected to when family members
leave the intervention which M1 and T2 linked to blame in the previous quotes.
21
M1... I‟m interested in the times when it doesn‟t work, ... I think they were some of the ones
that I was thinking about but not actually talking about because I wasn‟t quite sure how to
talk about them...you know catastrophic meetings that we‟ve had with people, where
somebody has stormed out and one of those, but I still feel guilty about it kind of umpteen
years later (L761-768).
Avoiding Blame
A number of techniques and ways of working were primarily used to avoid family
members experiencing a sense of blame during causality discussions. The sending
out of pre-intervention material was a way to avoid blame before the intervention
even started.
T3 ... the literature that we send out is, is quite, address the issue, that this is going to be done in a
non-blaming way. It‟s almost like, I think that message is sent out before people even arrive in the
sessions.
Other techniques used to avoid blame included empathy, particularly in the early
stages of the intervention and using the families own language. C4 spoke about
using ‘general terms’ to talk about sensitive issues without blaming and once a
formulation was constructed supervision was identified as important to check out if it
would be viewed as blaming/offensive to the family.
T2 ... you can bring them (formulations) to supervision so that other members of the team can hear.
You know, other members of the team being the sounding board. You know, have we phrased that
right? Does it sound harsh? Does that sound critical? (423-429).
Reducing Blame
Some groups talked about ways of intervening if someone felt blamed. These
included: looking for exceptions, asking the family how the blamed person might
view the situation, encouraging the blamed to attend, encouraging empathy/showing
empathy for the blamed. However one group felt that regardless of what you did
some people will continue to blame themselves.
T4 [Some people] with help, therapy, and whether that‟s individual or family can you know,
release themselves from the guilt...over a period of time and understand the model and the
22
way the model is delivered come to agree that their influence wasn‟t umm, perhaps as
significant as they first thought, but some people will blame themselves forever
T2 Yeah
T4 Forever and a day (L345-354).
Discussion
This research aimed to explore how clinicians discuss the causality of psychosis with
families within the FSS. Five of the seven themes identified were explored;
uncomfortable discussion; constructing a shared understanding; therapeutic style;
limiting exploration; blame.
The analysis found that causality was uncomfortable to discuss with families
because of factors that limited exploration and the role of blame. Clinicians said that
families sometimes ask to talk about causality, this permission giving made for a
more comfortable discussion. If not directly asked clinicians still aimed to talk about
causality. Rather than addressing it directly in a number of allocated sessions, as is
common in FM (Onwumere, et al. 2009) they ‘weaved’ the information in, to reduce
the risk of offending.
The development of a therapeutic-relationship enabled clinicians to discuss causality
more directly as it reduced the risk of family members being offended. It was also
identified as essential for engaging families and clients who had characteristics that
limited/prevented exploratory conversation, such as when families didn’t want to talk
and when clients were actively psychotic. This finding supports the strongly
established psychotherapy finding that the therapeutic-relationship is the most
important factor for therapeutic success (Rivett & Street, 2009; Wampold, 2001). For
the first time this analysis suggests the therapeutic-relationship is an important factor
23
for enabling the discussion of causality because it allows for a more direct and
comfortable discussion.
Causality discussions aim to construct a shared understanding of what caused the
psychosis. Three tools that are used for this are: the stress-vulnerability model
(SVM), genogram, and formulation. The SVM (associated with FM) was identified as
the most consistently used tool for constructing a shared understanding. This tool
allowed multiple causal factors to be considered in a way that wasn’t overly
confusing.
Read et al. (2006) criticism that the use of the SVM overemphasizes the biological
has been resolved by the FSS using it within the style of ‘exploratory conversation.’
In exploratory conversation the clinicians hold a not knowing stance whilst exploring
many different perspectives, with no one perspective being seen as true. Thus
biology isn’t emphasised more than other factors. The style of exploratory
conversation is akin to that used in OD and narrative approaches to FT, (White &
Epston, 1989; Seikkula, et al. 2001).
Doan, (1998, P. 383) criticised narrative approaches for downplaying the ‘genetically
likely stories.’ However, by using the SVM this criticism has been tackled, as genetic
vulnerability is an explicit part of the model. By integrating FT aspects (exploratory
conversation) with a FM tool (SVM) clinicians are able to have causality discussions
without over-emphasising or downplaying specific factors. This finding has clinical
application for those aiming for a balanced discussion about causality with families.
Causality is discussed in terms of linear rather than circular connections, most
commonly using the SVM. Although interactional cycles (circular connections) were
identified in the analysis they were used to construct a shared understanding about
24
what maintained the psychosis rather than what was causal. However, the focus of
the intervention goes beyond causality to moving the family forward. Interactional
cycles by exploring what maintains psychosis can be used to empower families to
change future interactional patterns. The advantage of integrating interactional
cycles had previously been cited by Burbach, et al. (2007) and is further supported
by this research. Future research could investigate if the integration of the SVM with
exploratory conversation to explore causality and the utilisation of circular
connections to explore maintenance fits with other services, interventions and
disorders.
Formulation is another means of constructing a shared understanding that combines
causality, maintenance and moving forward but formulation enables this to be done
within one tool. Formulation has an additional advantage, by exploring protective
factors it can identify strengths rather than solely focusing on problems. Stickley and
Matsterson (2003) argue that interventions that indentify strengths are more
empowering because they explore what is good and can be built upon compared to
just focusing on what needs to change. However, there was a risk of offending
families connected to formulation. Clinician’s spoke of constructing a formulation
without the family, checking it out in supervision to ensure it wasn’t likely to cause
offense and then sharing it. Thus families aren’t actively involved in constructing
formulations.
Genogram, the other tool identified was considered to be particularly good at getting
families actively involved but it only explores causality. Dallos and Stedman’s (2006)
suggestion of integrating the family’s genogram into their formulation may be a way
of bringing together the family involving advantage of genogram with the ability to
explore maintenance and moving forward inherent in formulation.
25
When the constructing a shared understanding matrix was looked at, it could be
seen that the two teams that had psychologists discussed formulation. Formulation is
a tool that is strongly based in the field of clinical psychology (Bentall, 2004) and
rarely used in approaches to working with families (Dallos & Stedman, 2006). This is
perhaps why it wasn’t discussed in the teams without psychologists. Similarly the
two teams that had family therapists discussed genograms perhaps because
genograms are a more significant part of their practice compared to other
professionals. This highlights the effect of professional backgrounds on causality
discussions. Family interventions are commonly delivered by clinicians with different
professional backgrounds (Rivett & Street, 2009) but how this effects the intervention
hasn’t been discussed until now. Future research into the effect of professional
background on family intervention would be interesting.
All the groups identified that the therapeutic style of matching the intervention to the
family was important, as it maintained engagement. Every group identified that
causality discussions generally took place within the style of exploratory
conversation. As previously discussed this style of approaching causality from a not
knowing stance ensured no one causal factor was over-emphasised. The flexibility to
switch to a psychoeducational style akin to FM was valued by some clinicians. There
was a sense that in certain situations, such as when substance misuse is discussed,
a psychoeducational style by informing family members can help prevent relapse
and or prevent family members from developing psychosis. However, some
clinicians felt that there was no need to switch to a psychoeducational style to
discuss causal factors
This may indicate a dilemma in integrating these two differing styles. Rivett and
Street (2009) suggest that a therapeutic stance of not knowing, which in part
26
describes exploratory conversation, is difficult to learn and comes with experience
because the family have an expectation that the clinician is expert and the clinician
experiences this as pressure to present themselves as expert. Thus the option of
using a psychoeducational style is an important choice for those clinicians who feel
uncomfortable with not knowing.
Clinician’s spoke about finding it difficult to explore causality when they acted as
care-coordinator, because the family wanted the more ‘active doing‟ role of care-
coordination which seemed at odds with exploratory conversation. In the current
economic climate where health providers are looking to save money, this research
highlights the clinical importance of having a separate care-coordinator.
Familial sexual abuse limited exploration because it didn’t feel appropriate to
explore. Research has suggested that familial sexual abuse is one of the major
causal factors in the development of psychosis (Read & Gumley, 2008). If not
explored the family’s understanding of causality won’t be complete. Beyond this the
recovery of the person experiencing psychosis will be limited and the abuse may
continue (Read & Gumley, 2008). One way identified that enabled familial sexual
abuse to be explored was by bring together only the family members that the abused
felt comfortable to discuss their experience with.
By seeing different combinations of family members the issue of confidentiality was
raised. The analysis identified that family members will often share information about
a particular causal factor (such as illicit drug use) in one combination of a family
meeting but prohibit clinicians from talking about it when other members of the family
are present. Larner (2000) argues that it’s the process of saying the unsaid that is
healing for families. It’s argued that in time it’s important to raise the unspoken
27
causal factor with the whole family. The analysis identified the development of the
therapeutic-relationship as one of the main means of making causality discussions
more comfortable. Rivett and Street (2009) argue that it’s the clinician’s ability to
contain that allows the unspoken to be spoken and containment is developed in part
through establishing the therapeutic-relationship (Wampold, 2001).
Some groups indicated that illicit drug use limited the exploration of causal factors
because exploratory conversation could become experienced as disagreement.
Rivett and Street (2009) identify that reflection allows the clinicians’ experience to be
communicated to families without them feeling the need to argue against it and the
analysis supports this assertion.
Blame had a major role in shaping causality discussions. Jones (2002) and Askey, et
al.’s (2009) finding that family members blamed each other is supported by
clinicians’ experience. However clinicians felt family members also blamed
themselves, which wasn’t found in the aforementioned research but does support the
research done by Gonzalez-Torres et al. (2006) and Corrigan and Miller (2004). The
same researchers’ finding that some families felt blamed by professionals was
supported by the current research.
Blame was identified as a major reason people disengaged from the intervention and
there was a strong expression of guilt from M1about when things went wrong and
people ‘stormed out.’ T3 commented that the pre-intervention literature sent out
communicated a message that the FSS was non-blaming. However, upon reviewing
the literature this message wasn’t borne out. It’s hypothesised that clinicians’ aim to
be non-blaming influenced their recollection of what was in the pre-intervention
literature.
28
A number of techniques that were used during causality discussion had a primary
function of avoiding blame. The introduction had identified that clinicians/researches
felt conversations in which there is no one, single, identifiable truth about causality,
only points of view (White & Epston, 1989; Seikkula, et al. 2001) was non-blamed.
Exploratory conversation that shares this aim was indentified in the analysis as non-
blaming, thus supporting this assertion.
Constructing circularities rather than linear connections had been suggested as a
way of discussing causality without blame (Jones & Asen, 2002). However, this
research found interactional cycles that draw circular connections were used to
discuss maintenance not causality. This research also identified using empathy,
using the families own language, talking in ‘general terms‟ and using supervision to
checkout formulations were ways of avoiding blame whilst constructing linear causal
connection.
Blame wasn’t always successfully avoided and when experienced clinician’s
described actively trying to reduce/resolve it. One technique used to do this was
expressing empathy for the blamed which has previously been described by
Burbach, et al. (2010). Other techniques that were described are generally
associated with FT (Dallos & Draper, 2005): looking for exceptions and asking the
family how an absent member would view the situation. However, until now these
techniques haven’t been explicitly identified as means of reducing/resolving family
member’s sense of blame. However, regardless of what clinicians do, some people
continue to blame themselves.
There seems to be a preconceived idea or as contended by Cecchin, et al. (2003) a
prejudice against blame. They recommend that clinicians’ prejudices be named and
29
explored within therapy. If this isn’t done they argue that open explorative thinking is
not modelled. Thus families are less able to share/explore their own prejudices which
they suggest are at the heart of families’ problems. The findings in the present
research appear to identify a prejudice that: „No one in the family should feel blamed
for the cause of psychosis.‟ Indeed the researcher now believes that his goal of
finding a way to „discuss causality without negative consequences’ was influenced
by this issue.
Martindale (2008) describes blame as a precursor to guilt. He argues that guilt can
be helpful as it can increase motivation to find a way of assisting the person
experiencing psychosis; psychodynamically this is called ‘reparative guilt’ (P.39) He
argues that to attempt to reduce/resolve this guilt would lessen motivation to help.
Thus it follows that if clinicians hold a prejudice against blame then the opportunity
for family members to experience reparative guilt is reduced and with it the
motivation to help.
Martindale (2008) also argues that guilt that is too unbearable may be projected onto
another person within the family; this is observed as one member blaming another.
Attempts to avoid/reduce this blaming won’t help the person projecting to integrate
this split off part of themselves. Martindale and others working psychodynamically
advocate exploring the blaming process and in so doing bring the dynamics of blame
to the families’ consciousness. It may be that some people continue to blame
themselves regardless of the FSS’s efforts because clinicians’ attempt to
avoid/reduce blame rather than explore it.
This research proposes that the psychodynamic literature on reparative and
projected guilt be utilised to further develop family interventions. It’s proposed that
30
clinical psychologists who through their training are experienced in drawing upon
different psychotherapy models to deliver interventions (including psychodynamics)
may be best placed to lead this development.
Focus group dynamics
The majority of comments were in general terms and even when directly asked for
practical examples participants found it difficult to provide them. Participants
identified talking in „general terms‟ as a technique they use with families to avoid
blame, perhaps they used this technique in the focus groups to avoid being seen as
blaming. Indeed M1appeared uncomfortable when he identified his comments about
complex families as blaming (P.21).
Participants often looked for reassurance from other members with the phrase ‘you
know?’ Reassurance was commonly provided with participants explicitly agreeing.
This level of agreement may have occurred because the participants’ views have
developed together over a period of joint working.
During the few disagreements participants were more likely to use examples from
practice. Kingsbury (1987) argues that it’s common for clinicians to give examples
from practice to support their position. However, by citing ones practice one is risking
this practice being criticised, perhaps another reason that practical examples were
rarely given. Thus participants self-censored what experience they shared, indeed
whilst reflecting on the focus groups the participants said they self-censored,
consequently the data available for analysis was affected by this social process.
Finally as a result of taking part in this research the FSS plan to set aside time to
focus on other topics of interest using a focus group methodology.
31
Limitations
Qualitative research doesn’t aim to be empirically generalisable. However it’s
desirable for implications of the research to inform practice. Given the homogeneity
of the sample, these findings will have the greatest relevance to clinicians within the
FSS. However, it’s hoped that these findings will enable clinicians in other services
to reflect on their practice.
Three members of the FSS were unable to attend the focus groups and the field
collaborator wasn’t invited given his involvement in the research. Therefore these
clinicians’ thoughts/influence didn’t contribute to the research. Thus this isn’t a
complete representation of the views of all FSS clinicians.
This research is dependent on clinicians’ views, with families’ voices being absent.
Asking families how they experienced causality discussions and observing family
intervention sessions in which causality was discussed would have improved the
robustness and scope of the research. Unfortunately given the time restraints this
wasn’t possible. However research using such a triangulation of methods into the
issue of blame is currently in development.
It’s important to highlight that the focus groups were conducted in a limited time
frame (one hour) amongst clinicians who knew each other well and that the groups
took place on work premises. Thus it may be that participants responded in a more
professional manner than they would have done if they had more time, a different
setting and they were less familiar with each other. In part this might be why there
was little emotion within the majority of comments, there were high levels of
agreement and few practical examples given.
32
This research focused on causality discussions but this only makes up part of family
interventions. It was difficult to hold the focus on how clinicians’ discuss causality
from drifting wider to how they undertake family interventions. It was artificial to focus
on causality and a more accurate picture may have been gained by exploring the
whole intervention. However, as framework analysis allows for a-prior and in-vivo
analysis, the wider scope of family interventions was acknowledged.
33
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40
Extended appendices
Appendix A: Invitation to participate
Appendix B: Consent form
Appendix C: Participant information sheet
Appendix D: Semi-structured focus group interview guide
Appendix E: A table detailing the stages of framework analysis
Appendix F: Questions used to structured the feedback focus group
Appendix G: Feedback focus group summary
Appendix H: An excerpt from a theme chart
Appendix I: An example of a thematic map
Appendix J: An example of a theme matrix
Appendix K: An example of an interpretation sheet
Appendix L: An example of indexed transcript
Appendix M: An excerpt from the research diary
Appendix N: Theme summary table
Appendix O: Participant demographic information table
Appendix P: Family Process, author guidelines
Appendix Q: Confirmation of ethical approval
Appendix R: Dissemination strategy
Appendix S: Glossary of terms
Appendix T: An example of a circularity
Appendix U: An example of a genogram
Appendix V: An example of an interactional cycle
41
Invitation to participate
Dear
My name is Andrew Newman and I recently attend your family support service team meeting
and talked to you about the research we hope to undertake. We plan to run a series of focus
groups to gain clinician‟s experience of discussing causality with families. Thus we are
inviting you to take part in a focus group discussion. The focus group will be held after your
team meeting in your team base. It will last for up to one hour and be recorded onto audio
tape.
If you would like to take part in the research please opt in by respond to this e-mail. An
information sheet and consent form are attached.
If you are interested in taking part I will contact you with the focus group dates and details.
Thank you
Andrew Newman (the researcher)
Trainee Clinical Psychologist
Exeter University and Somerset Partnership Trust
42
Consent form Participant Identification Number for this trial: CONSENT FORM Title of Project: The experience of clinicians in discussing causality with
families in a family management and therapy integrated service.
Name of Researcher: Andrew Newman. Please initial box. 1. I confirm that I have read and understand the information sheet for the above study. I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily. 2. I understand that my participation is voluntary and that I am free to withdraw at any time without giving any reason and my withdrawal will have no adverse effect upon me. 3. I understand that the focus group will be audio recorded and data collected during the study may be looked at by individuals from Exeter University, from regulatory authorities or from the NHS Trust, where it is relevant to my taking part in this research. I give permission for these individuals to have access to audio recordings of me obtained at the focus group. 4. I agree to take part in the above study and give consent for direct quotes to be taken. ______________________________ _________________ _________________________ Name of clinician Date Signature ______________________________ _________________ _________________________ Name of person taking consent Date Signature
One copy to participant and one copy to researcher
43
Information sheet
Theories regarding the cause of schizophrenia have divided family management and therapy
for over a hundred years. Now as researchers/clinicians attempt to integrate the two
approaches the experience of discussing the causes of psychosis with families is important to
research. To do this the wealth of knowledge clinicians have about discussing causality with
families will be explored.
We plan to run a series of focus groups to gain clinicians‟ experience of discussing causality
with families. Thus we are inviting you to take part in a focus group discussion. The focus
group will be held after your team meeting in your team base. It will last for up to one hour
and be recorded by audio tape.
Do I have to take part?
It is up to you to decide. We are happy to describe the study and go through this information
sheet with you if you want. If you feel like you would like to take part we ask that you reply
to an e-mail invitation to take part. You are free to withdraw at any time, without giving a
reason. This would not affect you in any way. You will have the opportunity to ask questions
on the day of the focus group, and you will be asked to sign a consent form before it begins.
What are the advantages and disadvantages of taking part?
It will take about 60 minutes of your time to take part in the focus group and the focus group
may bring up some uncomfortable feelings. However the researcher will make himself
available at the end of the focus group to discuss uncomfortable feelings that may arise.
The main advantages will be the creative experience, the potential to explore your practice in
a reflective space and the opportunity to add your views to the body of literature.
Will I find out what happens after I’ve taken part?
In keeping with the commitment to research „with people rather than on people‟ the findings
will be taken back to the participants to clarify points and secure consensus in a follow up
focus group to which all participants will be invited. You will also have the opportunity to
request a copy of the research once completed.
What if I have concerns or want to complain about the way I’ve been treated?
If you have any concerns or wish to complain you can do so by e-mail to Janet Reibstein
[email protected] who is supervising this project. Or to Frank Burbach who is my
field collaborator by e-mail at [email protected].
44
Will the information be kept confidential?
Names will be changed in the write up. The code, the audio recordings and transcripts will be
secured in a locked drawer. Confidentiality and anonymity can only be guaranteed from the
researcher‟s personal perspective, but this cannot be guaranteed on behalf of the co-
participants. The only time we may break confidentiality would be if we were concerned
about others safety. In this event we would inform you first if possible.
Please feel free to ask us if there is anything that is not clear or if you would like more
information. You can contact the researcher by e-mail at [email protected].
Take time to decide whether or not you wish to take part. The researcher will contact you by
e-mail near the time of the focus group to see if you wish to participate.
Thank you
Andrew Newman
Trainee Clinical Psychologist
Exeter University and Somerset Partnership Trust
45
Semi-structured focus group interview guide
This semi-structured guide was generated by the researcher following the literature
review. It was reviewed by the research supervisor and field collaborator and piloted
on a focus group of five trainee clinical psychologists.
What are the clinicians’ ideas/hypotheses about causality?
Can you write on the flip chart paper provided what factors you feel have a causative role in psychosis
Do clinicians discuss causality with families?
Which factors wouldn’t you discussed with families?
Can you tell me a bit more about these discussions?
If you haven‟t discussed any causative factors with families why haven‟t you?
What has been their experience of discussing causality with families?
Can you tell me about when a discussion went well?
Can you tell me about a discussion that didn’t go so well?
You mentioned using ........... to discuss the cause of psychosis with a family, can you tell me more about that?
Have you used any other specific techniques to discuss causality?
How do you decide which techniques to use?
What are the clinicians’ reflections on talking about these issues within the focus group?
What are your reflections on talking today about issues around causality?
46
Table 1. Stages of framework analysis (krueger & casey, 2009; rabiee, 2004;
ritchie & spencer, 1994).
Framework stages Description of stages Familiarisation Transcribing the data, reading and re-
reading the transcripts. The aim to immerse oneself in the detail and get a sense of the data as a whole before the data is broken into parts
Identifying a thematic framework Writing memos in the margins of the text, in the form of short phrases, ideas or concepts that arise from the text. The aim to begin to categorise the data and develop descriptive statements
Indexing Identifying portions of the data that correspond to a particular theme and noting the theme in the margin of the text.
Charting Cutting up the transcript and sorting all the quotes that address a particular question together (deductive). Also allowing themes that were constructed by the participants (inductive) to be collected. Data that is not considered relevant is put to one side. The ‘long table’ approach. Microsoft word cut and paste function was used to undertake this stage of analysis.
Mapping and Interpreting Map The codes identified within a theme are mapped.
Matrix A matrix is developed for each theme. The matrix contains distilled summaries of each theme and allows for the focus groups to be compared in relation to each theme.
Words Considering the actual words used and their meaning.
Context Consider the context.
Internal consistency Consider changes in opinion or position.
Frequency Consider how often a comment or view is made.
47
Intensity of comment Consider the depth of feeling in which comments or feeling are expressed.
Specificity of response Greater emphasis placed on participants referring to personal experience rather than hypothetical situations.
Extensiveness The number of participants who express a particular view and deviant cases.
Big Picture Consider larger trends or concepts that cut across the various discussions, whilst holding an awareness of deviant cases.
48
Guide for focus group feedback session
Do they recognise the maps? Are the factors within the maps grouped appropriately? Are they labelled appropriately? Have I missed anything?
What factors do they think are most important?
49
Focus group feedback summary
10/02/11
The feedback group lasted for one hour. It included the following people.
M2, M3, M5, T2, T4, C1, C3, C5, Y3
Generally the participants recognised the maps and my descriptions and they
reflected that they were true accounts of their practice. They highlighted that
discussions about causality begin amongst themselves before family
interventions, with other professionals and in supervision regarding the
referral.
They felt it was also important to highlight that it was very rare to have less
than two clinicians facilitating sessions. They felt it was important to highlight
that there can be contact with members of the family outside the sessions and
that family sessions can happen in trust properties and in the family’s home.
There was also a discussion about changing the word wondering to reflecting.
‘playing the other card‟ wasn’t recognisable and following a description of the
box, the title ‘reflecting counterintuitively‟ was felt to fit better. Within the
‘reflecting‟ factor the box titled ‘to myself‟ was considered confusing as it did
not indicate that this reflecting was shared with the family. Therefore the term
‘sharing self reflection‟ was chosen instead.
It was felt the ‘fun‟ box linked to Genograms was misleading as genograms
are often very emotive. This box was felt to be better described as active.
M2
M3 T2
T4
C1
M5
AN
C1
M5 C5
Y3
C3
50
In closing again the participants commented on how useful the focus group
experience was and they said they were going to try and integrate focus
groups into their practice.
51
An excerpt from the therapeutic style chart
Therapeutic Style
Matching
AN So you would do it as a kind of education?
C1 Umm
AN And would you cover all those? (referring to white board)
C5 Umm, yeah. Not necessarily either it is very dependent on the situation and the family,
doesn‟t it? Some families are better at communicating or asking for information, I think it‟s
very dependent and very individually assessed really as to how you mange that. And I don‟t
think you would necessarily cover all that in one particular, it would depend on the session
and (L98-106)
Y2 Yeah second year or maybe third year even and I might not even go there at all.
You know it depends on whether they were future orientated or past orientated
AN Can you say more about that distinction?
Y2 Some people are umm very sort of psychoanalytical in the way they understand the world.
And so very interested in umm hearing about past generations. Some people are very in the
present and future and not really, actually have an abhorrence sometimes, you know
sometimes an embargo is put on what you can talk about. People will sometimes say I‟m not
going to talk to you, you know if you keep talking about the past, you know I want to put that
behind me. So it‟s very important to discuss causes in a context that the family creates for
you. And umm, and weave that information in. Through questions and through exploration
rather than as traditionally presenting it, like we‟re going to do stress vulnerability today, you
know. They put that, that can be really good for some families and the kiss of death for
others, you know, so (L222-235)
M2 that that struck me also about that actually you know, there are a number of tools
around, there are a number of things you could use, a number of techniques but which
you actually use and how you use them depends upon the family that you‟re with,
what they‟re seeking, what they‟re looking for and sometimes there‟s a sort of
matching sort of process I think, about trying to, trying to link
M3 Yes, that‟s a nice way of putting it matching process, yes. (L562-569)
M2 But it‟s, but it‟s based upon the sort of, you know you say. I mean it struck me as
sort of what do you think, what are the needs of the family at that time
M4 Yeah, exactly, yeah
52
M2 And if the needs are for something to be more structured, then that‟s what one provides,
if the needs are for something more discursive and then (L616-622)
T3 I think inevitably yes. Well sometimes we, well you know, we will say to them,
you know a view that, people will come with a view that their psychosis was caused
by substances misuse and we look at that and think why the substance misuse, what
are they trying to manage. So we, we play the other card sometimes. And it‟s not
fixed, I think whatever we say bearing in mind, you have to contextualise that with
the family you are with and the material their bringing and the history of previous
meetings. I think it‟s
AN So it sounds like your approach might be different depending on which family you are
with? Each family might be different?
(10 seconds of silence)
T3Yes and no, there‟s the element which, you know we‟re always brining ourselves aren‟t
we? And how we are, umm but I think we do have to be sensitive to that individual families
needs as well. (L545-559)
C4 And we work with individual families very, very differently I think. I mean
All Hmm, yeah (L227-229)
Y3 I guess really we would talk about whatever is relevant for that family. (L200-
201)
53
Interpretation of: therapeutic skills theme
Words
They spoke of matching their interventions to the family’s needs in order to increase
the likelihood of the family engaging. They said causality discussions generally took
place within a style of ‘explorative conversation.’ This term was chosen in the
feedback focus group. Some of the focus groups spoke of a need to change to a
more psychoeducational style at times, particularly when discussing illicit drugs and
alcohol. There was some disagreement about the need to change styles. All the
focus groups commented that although the research’s focus is on causality the
interventions focus is on looking for options to change the future.
Context
The semi-structured interview guide did not have a question about this theme but it
was mentioned in every focus group. The majority of comments were in general
terms but practical examples were given during the disagreement about the need to
change styles.
Internal consistency
There was disagreement about changing styles.
Frequency
This theme was talked about frequently and discussed at length in all focus groups.
Intensity of comments
The conversations were generally reflective and there was little emotion within the
conversations.
Specificity of response
The majority of comments were in general terms but practical examples were given
during the disagreement about the need to change styles.
Extensiveness
Every focus group mentioned all of these factors.
Big picture
The factors within this theme were considered the most important for successful
discussions about causality to take place. There was an important point made that
the interventions focus is not on causality but on options to change the future. This
theme captured some disagreement around changing style, perhaps this tension
comes from the challenge of integrating FT and FM.
54
Limiting exploration
Limiting exploration
Familiar abuse
Having to be the
care-coordinator
Client factors Family factors
Not
knowing
Can’t do
therapy
Confidentiality
Early
stage of
psychosis
Too
unwell
Too in
their
body
Complex Focus on
one factor
Reflection
to help
explore
Therapeutic
relationship
can help
Feels
isolated
Not
wanting
FI
Different
combinations
helps Want
to
divest
self
Don’t
talk
Illicit drug use
Risk of
disagreement
55
Constructing a shared understanding
Stress Vulnerability model Genogram Formulation Interactional cycles
M S-V model used a lot, as individual.
Question what is stress and
vulnerability.
Positives
Takes blame out of the equation.
Can draw a graph.
Empowering.
Reduces fait accompli.
Uncovers trauma and
genetic factors.
Get‟s people involved.
Combining S-V model and interactional cycles. S-V
model for causality and interactional cycles for how
it gets played out.
Blame doesn‟t get centred on one person.
Someone felt blamed following drawing out the
interactional cycle.
T S-V model used a lot, mentioned in
nearly every session.
Positives
Non-blaming.
It is a gentle and kind model.
It is easy to understand.
Good for introducing causality
If people ask about causality it is
good.
It is flexible
Can be visual
Can draw a graph
Covers all factors.
Negative
But people can still feel blamed,
doesn‟t wash it away.
Looks at what caused it, how it gets
played out and how people can move
on.
Formulations written outside sessions,
pulling together the conversations.
People can change it and something‟s
may be left out.
Validating.
Empowering.
Powerful.
Objective.
Gives a new understanding
You need supervision as very sensitive.
Use the formulation to set goals.
Use interaction cycles.
The participant spoke about drug use in an
interactional cycle way.
Look at maintenance rather than causality.
People can feel blamed following the drawing out of
the interactional cycle.
C I‟d discuss causality using the S-V
model.
Positives
It is easy to understand.
Can work even if no psychosis.
Negative
People who want medical find it to
woolly.
We share the formulation with the
family.
Y Positives
It is flexible.
Can be visual
Tidiness and chaos can both be
stressors. Complicated but
achievable.
Negative
People may not appreciate the
jargon.
Used to attack person with psychosis.
Good for getting to
know people.
Uncovers trauma and
genetic factors.
But need to be careful.
Conflict around do it
early on or later.
Get‟s people involved.
It‟s an active tool.
56
57
Research diary excerpt
09/11/10
B focus group
The stress-vulnerability model came up again and formulation also did. There was a very strong emphasis on the therapeutic-relationship. I was interested to hear about the importance of not being the care-coordinator. It was interesting that care-coordination seems a more ‘active doing’ role. There was talk about talking differently with staff compared to families. The conversation seemed to go more off topic for this group. We covered a bit about bringing in people who hadn’t been at a previous session but this was a little off topic. It will be interesting when I’m listening back to see how much is usable and how much was off topic. I’m not sure why we went off topic, maybe because it was the third group? Maybe the people in the group played a factor in this? It may be that when I listen back that it wasn’t as off topic as it felt. Even reflecting upon it now it seems like lots of relevant material was aired. I defiantly think I am building on information and certainly getting a fuller idea of how clinicians tackle the subject of causality. Yeah generally a good day. One focus group to go…..
58
Table 2. Theme summary table
Themes Factors that made up the theme
Uncomfortable
discussion
Discussions more comfortable when families asked to talk about causality.
Discussions more comfortable if causality ‘weaved’ in.
Discussions more comfortable if therapeutic-relationship established.
Constructing a
shared
understanding
Can use the Stress-Vulnerability Model
Can use Genograms
Can use Formulation
Interactional cycles identified but to explore maintenance not causality.
Therapeutic
skills
Matching the intervention to the family’s preferences.
Using a therapeutic style of exploratory conversation.
The flexibility to use a psychoeducational style
Therapeutic focus on changing the future
Limiting
exploration
Suspecting familiar sexual abuse. Resolved by seeing different combinations of family members
Confidentiality puts blocks on what can be discussed.
Discussions about illicit drug use lead to disagreement. Resolved by using reflection.
Care-coordinator role is more active than family role, so hard to hold both.
Client specific factors and family specific factors. Resolved by establishing a therapeutic-relationship.
Blame Role of blame Avoiding blame Reducing Blame
People blaming themselves.
Family members blaming each other.
Family members feeling blamed by clinicians.
Blame is the main reason people don’t attend or drop out.
Clinicians express guilt about when it goes wrong.
Pre-intervention material.
Using the families own language.
Talking in general terms.
Using supervision to check out formulations.
Looking for exceptions.
Psychologically bring the blamed into the room.
Encouraging the blamed to attend.
Showing empathy for the blamed.
Sometimes cannot reduce blame.
59
Participant demographic information table
Focus group
Gender Profession Additional psychotherapy qualifications
Length of
Service
Time in FSS
M Female Social Worker Psychodynamic Therapy
21 8
M Male Art Psychotherapist
Family Therapy 40 13
M Male Family Therapist None 10 9
M Male Registered Mental Health Nurse (RMN)
None 7 5
M Female Registered Mental Health Nurse (RMN)
Family Therapy 19 13
M summary
2 female and 3 male
1 Art Psychotherapist,
2 RMNs, 1 Family Therapist
and 1 Social Worker
2 additionally trained in
family therapy, and 1 has done psychodynamic
therapy
Mean length
of service
19 years
Length of
service range 7-40
years
Mean time in
FSS 10 years Time in
FSS range 5-13 years
C Male Did not provide details
Declined to provide details
Declined to
provide details
Declined to
provide details
C Female Did not provide details
Did not provide details
Did not provide details
Did not provide details
C Male Registered Mental Health Nurse (RMN)
Cognitive Behavioural
Therapy
21 11
C Female Social worker None 16 11
C Female Social Worker Psychodynamic Therapy
8 5
C Summary
3 female and 2 male
1 RMN, 2 social workers and 2 clinician’s did
not provide details
1 additionally trained in Cognitive
Behavioural Therapy, 1 in
psychodynamic therapy and 2
did not provide details.
Mean length
of service
15 years
Length of
service
Mean time in FSS
9 years Time in
FSS range 5-11 years
60
range 8-21
years
T Female Occupational Therapist
Cognitive Behavioural
Therapy
20 10
T Female Registered Mental Health Nurse (RMN)
None 7 4
T Male Did not provide details
Did not provide details
Did not provide details
Did not provide details
T Male Social Worker None 15 6
T Summary
2 female and 2 male
1 Occupational Therapist, 1
RMN, 1 Social worker and 1 did
not provide details
1 additionally trained in cognitive
Behavioural Therapy and 1 did not provide
details.
Mean length
of service
14 years
Length of
service range 7-20
years
Mean time in
FSS 7 years Time in
FSS range 4-10
years
Y Female Did not provide details
Did not provide details
Did not provide details
Did not provide details
Y Male Registered Mental Health Nurse (RMN)
Family Therapy 31 13
Y Female Registered Mental Health Nurse (RMN)
Family Therapy and Cognitive Behavioural
Therapy
33 9
Y Female Did not provide details
Did not provide details
Did not provide details
Did not provide details
Y Summary
3 female and 1 male
2 RMNs and 2 did not provide
details
2 additionally trained in
family therapy, 1 in cognitive behavioural
Therapy and 2 did not provide
details
Mean length
of service
32 years
Length of
service range 31-33 years
Mean time in
FSS 11 years Time in
FSS range 9-13
years
61
Total summary
8 males and 10 females
1 Family Therapist, 1
Occupational Therapist, 1 Art Psychotherapist,
4 Social workers, 6
RMNs and 5 did not provide
details
2 additionally trained in
psychodynamic therapy, 3 in
cognitive behavioural therapy, 4 in
family therapy and 5 did not
provide details.
Mean length
of service
19 years
Length of
service range 7-40
years
Mean time in
FSS 9 years Time in
FSS range 4-13
years
62
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South West 5 REC
formerly Frenchay REC
C/o North Bristol NHS Trust
Beaufort House
Southmead Hospital
Westbury-on-Trym
Bristol
BS10 5NB
Telephone: 0117 323 5211
Facsimile: 0117 323 2832
23 July 2010
Mr Andrew Newman
Trainee Clinical Psychologist
University of Exeter and Taunton and Somerset Foundation Trust
Washington Singer Laboratories
Perry Road
Exeter
EX4 4QG
Dear Andy
Study Title: The experience of clinicians in discussing causality with families in a family management and therapy integrated service
REC reference number: 10/H0107/42
Thank you for your letter of 17 July 2010, responding to the Committee’s request for further information on the above research and submitting revised documentation.
The further information has been considered on behalf of the Committee by the Chair.
Confirmation of ethical opinion
67
On behalf of the Committee, I am pleased to confirm a favourable ethical opinion for the above research on the basis described in the application form, protocol and supporting documentation as revised, subject to the conditions specified below.
Ethical review of research sites
The favourable opinion applies to all NHS sites taking part in the study, subject to management permission being obtained from the NHS/HSC R&D office prior to the start of the study (see “Conditions of the favourable opinion” below).
Conditions of the favourable opinion
The favourable opinion is subject to the following conditions being met prior to the start of the study.
Management permission or approval must be obtained from each host organisation prior to the start of the study at the site concerned.
For NHS research sites only, management permission for research (“R&D approval”) should be obtained from the relevant care organisation(s) in accordance with NHS research governance arrangements. Guidance on applying for NHS permission for research is available in the Integrated Research Application System or at http://www.rdforum.nhs.uk. Where the only involvement of the NHS organisation is as a Participant Identification Centre (PIC), management permission for research is not required but the R&D office should be notified of the study and agree to the organisation’s involvement. Guidance on procedures for PICs is available in IRAS. Further advice should be sought from the R&D office where necessary. Sponsors are not required to notify the Committee of approvals from host organisations. It is the responsibility of the sponsor to ensure that all the conditions are complied with before the start of the study or its initiation at a particular site (as applicable). Approved documents The final list of documents reviewed and approved by the Committee is as follows:
Document Version Date
Investigator CV 03 June 2010
Protocol 3 22 March 2010
Supervisor CV
REC application
Covering Letter 03 June 2010
Covering Letter
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Summary/Synopsis 1 03 June 2010
Letter from Sponsor 27 May 2010
Interview Schedules/Topic Guides 2 22 March 2010
Letter of invitation to participant 1 22 March 2010
Participant Information Sheet 3 17 July 2010
Response to Request for Further Information
Participant Consent Form 4 17 July 2010
Public Liability 22 July 2009
Field Collaborator Cv 03 June 2010
Major Risk Matrix 3 03 June 2010
Evidence of insurance or indemnity 17 August 2009
Referees or other scientific critique report 20 April 2010
Statement of compliance
The Committee is constituted in accordance with the Governance Arrangements for Research Ethics Committees (July 2001) and complies fully with the Standard Operating Procedures for Research Ethics Committees in the UK.
After ethical review
Now that you have completed the application process please visit the National Research Ethics Service website > After Review
You are invited to give your view of the service that you have received from the National
Research Ethics Service and the application procedure. If you wish to make your views known please use the feedback form available on the website.
The attached document “After ethical review – guidance for researchers” gives detailed guidance on reporting requirements for studies with a favourable opinion, including:
Notifying substantial amendments
Adding new sites and investigators
Progress and safety reports
Notifying the end of the study
The NRES website also provides guidance on these topics, which is updated in the light of changes in reporting requirements or procedures.
We would also like to inform you that we consult regularly with stakeholders to improve our service. If you would like to join our Reference Group please email [email protected].
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10/H0107/42 Please quote this number on all correspondence
Yours sincerely
Dr Mike Shere
Chair
Email: [email protected]
Enclosures: “After ethical review – guidance for researchers” SL- AR2
Copy to: Andy Richards, Exeter University
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Dissemination strategy
As the finding from this research will have the greatest relevance to clinicians within
the FSS this paper will be sent to every member of the service once finalised. A
reflective space will be offered to the service to provide them with the opportunity to
reflect upon the paper and identify points they wish to take forward.
As this research will be of direct relevance to clinicians practicing family interventions
within Early Intervention in Psychosis services a poster will be submitted to the UK
and South West Early Intervention in Psychosis annual conference/meetings.
The target journal for this research is the ‘British Journal of Clinical Psychology‟ as among
other research this journal publishes studies of psychological interventions with families.
The journal’s target audience of clinical psychologists is well suited to this paper as it
argues that they are the best placed to further develop family interventions for psychosis.
The journal is also read by other mental health professionals and has a worldwide
audience. Finally the journal has a proven record of publishing qualitative research.
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Glossary of Terms
“Circularity: The situation where what happens is in some way determined by
some precursor event and has also had some effect on that first event, where it is
not possible to determine „which came first, the chicken or the egg‟. This way of
viewing the world grew out of biology and ecology. It is consistent with a linear
conception if the latter is seen as treating just one small segment of a larger
interrelated whole” (Dalos & Draper, 2005, P 305). (See appendix T for an example)
Exploratory conversation: Are conversations in which clinician’s take a non-expert
position and hold a stance that there is no one, single, identifiable truth about
causality, only points of view. They invite member’s of the family to share their views
and facilitate an atmosphere in which uncertainty/not knowing is encouraged.
Formulation: A formulation describes the problem (psychosis), the predisposing
(causal) factors, perpetuating (maintaining) factors and the protective (things that the
family can do more of) factors. Formulations as used by the FSS are constructed by
the clinicians and then shared with the family.
Genogram: A genogram is a pictorial representation of the people in a person’s
family. In clinical practice additional lines are added to demonstrate the strength of a
relationship with straight lines representing a strong relationship and wave lines
representing a conflictual relationship (see appendix U for an example).
Interactional cycles: Interactional cycles are similar to circularities in that they are
interested in the large interrelated whole, but interactional cycles also make
cognitions/attributions about family members explicit, see Burbach, et al, (2007) for
examples of interactional cycles (see appendix V for an example).
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Psychoeducation: Psychoeducation is a style of intervention in which traditionally
information on ‘what is known’ about a psychologically related topic is presented to a client
and or family by a clinician/clinicians from an expert position.
Stress-vulnerability model (SVM): This model was purposed by Zubin and Spring (1977)
and describes a vulnerability to psychosis being present at birth or soon after. However
just because one is vulnerable to psychosis does not mean one will develop it, as there
needs to also be an exposure to stress. This stress can be acute, in terms of major life
events or ambient, which comes from accumulated day-to-day stressors of life.
References
Burbach, F., Carter, J., Carter, J., & Carter, M. (2007). Assertive Outreach and
Family Work. In: Velleman, R., Davis, E., Smith, G., & Drage, M. (Eds.) Changing
Outcomes in Psychosis, Collaborative Cases from Practitioners, Users and Carers.
Oxford, BPS Blackwell.
Dallos, R. & Draper, R. (2005). An Introduction to Family Therapy, systemic theory
and practice, (2nd edn). Maidenhead, Berkshire, Open University Press.
Zubin, J. & Spring, B (1977). Vulnerability: A new view of schizophrenia. Journal of
Abnormal Psychology 86, 103-126.
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